BCBSVT Gold Plan - 13627VT0320002 Health Insurance Plan
Blue Cross and Blue Shield of Vermont health insurance plan with the Plan ID 13627VT0320002. The plan is called BCBSVT Gold Plan.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.90% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.10% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.31% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.69% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 13627VT0320002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Vermont | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of Vermont | ||||||||||||||||||
| Health Insurance Plan Variant | 13627VT0320002-01 | ||||||||||||||||||
| Provider Network(s) | ['VTN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
BCBSVT Gold Plan Health Insurance Plan Variant 13627VT0320002-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.813100216 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Maximum Out of Pocket for Drug EHB Benefits, Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Drug EHB Benefits, Combined In/Out Network, Individual | Not Applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $200 per person | $400 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $200 |
| Drug EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Drug EHB Benefits, In Network (Tier 1), Individual | $1,400 |
| Maximum Out of Pocket for Drug EHB Benefits, In Network (Tier 2), Individual | $1400 per person | $2800 per group |
| Maximum Out of Pocket for Drug EHB Benefits, Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Drug EHB Benefits, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, High Blood Pressure & High Cholesterol |
| First Tier Utilization | 100% |
| Formulary ID | VTF003 |
| HIOS Product ID | 13627VT032 |
| HSA/HRA Employer Contribution | No |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.90% |
| Issuer ID | 13627 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | No |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | Not Applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $1400 per person | $2800 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,400 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family | $5600 per person | $11200 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $5,600 |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | VTN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | All members traveling outside the U.S. have access to the BlueCard Worldwide program. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Members may use preferred providers nationally through the BlueCard network. |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 13627VT0320002-01 |
| Plan Marketing Name | BCBSVT Gold Plan |
| Plan Type | EPO |
| Plan Variant Marketing Name | BCBSVT Gold Plan |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $2,570 |
| SBC Scenario, Having a Baby, Copayment | $30 |
| SBC Scenario, Having a Baby, Deductible | $1,400 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,110 |
| SBC Scenario, Having Diabetes, Deductible | $910 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $350 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,150 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | VTS001 |
| Source Name | SERFF |
| Plan ID | 13627VT0320002 |
| State Code | VT |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of BCBSVT Gold Plan Health Insurance Plan, 13627VT0320002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about BCBSVT Gold Plan, 13627VT0320002 Health Insurance Plan, 13627VT0320002
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Does BCBSVT Gold Plan Health Insurance Plan, 13627VT0320002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (13627VT0320002) Health Insurance Plan, Variant (13627VT0320002-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, High Blood Pressure & High Cholesterol
Does (13627VT0320002) Health Insurance Plan, Variant (13627VT0320002-01) have Out Of Country Coverage?
Yes. Details: All members traveling outside the U.S. have access to the BlueCard Worldwide program.
Does (13627VT0320002) Health Insurance Plan, Variant (13627VT0320002-01) have Out of Service Area Coverage?
Yes. Details: Members may use preferred providers nationally through the BlueCard network.
Does (13627VT0320002) Health Insurance Plan, Variant (13627VT0320002-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, High Blood Pressure & High Cholesterol
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0320002-01) offer Disease Management Programs for Asthma?
Yes, the BCBSVT Gold Plan Health Insurance Plan Variant
13627VT0320002-01 offers Disease
Management Program for Asthma.
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0320002-01) offer Disease Management Programs for Heart disease?
Yes, the BCBSVT Gold Plan Health Insurance Plan Variant
13627VT0320002-01 offers Disease
Management Program for Heart disease.
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0320002-01) offer Disease Management Programs for Depression?
Yes, the BCBSVT Gold Plan Health Insurance Plan Variant
13627VT0320002-01 offers Disease
Management Program for Depression.
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0320002-01) offer Disease Management Programs for Diabetes?
Yes, the BCBSVT Gold Plan Health Insurance Plan Variant
13627VT0320002-01 offers Disease
Management Program for Diabetes.
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0320002-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the BCBSVT Gold Plan Health Insurance Plan Variant
13627VT0320002-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does BCBSVT Gold Plan Health Insurance Plan, Variant (13627VT0320002-01) offer Disease Management Programs for Pregnancy?
Yes, the BCBSVT Gold Plan Health Insurance Plan Variant
13627VT0320002-01 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API